Pediatric Emergency Care Applied Research Network Research Articles

Validation of Prediction Rules for Computed Tomography Use in Children With Blunt Abdominal or Blunt Head Trauma: Protocol for a Prospective Multicenter Observational Cohort Study.

Traumatic brain injuries (TBIs) and intra-abdominal injuries (IAIs) are 2 leading causes of traumatic death and disability in children. To avoid missed or delayed diagnoses leading to increased morbidity, computed tomography (CT) is used liberally. However, the overuse of CT leads to inefficient care and radiation-induced malignancies. Therefore, to maximize precision and minimize the overuse of CT, the Pediatric Emergency Care Applied Research Network (PECARN) previously derived clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma in large cohorts of children who are injured. This study aimed to validate the IAI and age-based TBI clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma. This was a prospective 6-center observational study of children aged <18 years with blunt torso or head trauma. Consistent with the original derivation studies, enrolled children underwent routine history and physical examinations, and the treating clinicians completed case report forms prior to knowledge of CT results (if performed). Medical records were reviewed to determine clinical courses and outcomes for all patients, and for those who were discharged from the emergency department, a follow-up survey via a telephone call or SMS text message was performed to identify any patients with missed IAIs or TBIs. The primary outcomes were IAI undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries) and clinically important TBI (death from TBI, neurosurgical procedure, intubation for >24 hours for TBI, or hospital admission of ≥2 nights due to a TBI on CT). Prediction rule accuracy was assessed by measuring rule classification performance, using standard point and 95% CI estimates of the operational characteristics of each prediction rule (sensitivity, specificity, positive and negative predictive values, and diagnostic likelihood ratios). The project was funded in 2016, and enrollment was completed on September 1, 2021. Data analyses are expected to be completed by December 2022, and the primary study results are expected to be submitted for publication in 2023. This study will attempt to validate previously derived clinical prediction rules to accurately identify children at high and very low risk for clinically important IAIs and TBIs. Assuming successful validation, widespread implementation is then indicated, which will optimize the care of children who are injured by better aligning CT use with need. RR1-10.2196/43027.

Validation and comparison of the PECARN rule, Step-by-Step approach and Lab-score for predicting serious and invasive bacterial infections in young febrile infants

Differentiating infants with serious bacterial infections (SBIs) or invasive bacterial infections (IBIs) from those without remains a challenge. We sought to compare the diagnostic performances of single biomarkers (absolute neutrophil count [ANC], C-reactive protein [CRP] and procalcitonin [PCT]) and 4 diagnostic approaches comprising Lab-score, Step-by-Step approach (original and modified) and Pediatric Emergency Care Applied Research Network (PECARN) rule. This is a prospective cohort study involving infants 0-90 days of age who presented to an emergency department from July 2020 to August 2021. SBIs were defined as bacterial meningitis, bacteraemia and/or urinary tract infections. IBIs were defined as bacteraemia and/or bacterial meningitis. We evaluated the performances of Lab-score, Step-by-Step (original and modified) and PECARN rule in predicting SBIs and IBIs. We analysed a total of 258 infants, among whom 86 (33.3%) had SBIs and 9 (3.5%) had IBIs. In predicting SBIs, ANC ≥4.09 had the highest sensitivity and negative predictive value (NPV), while PCT ≥1.7 had the highest specificity and positive predictive value (PPV). CRP ≥20 achieved the highest area under receiver operating characteristic curve (AUC) of 0.741 (95% confidence interval [CI] 0.672-0.810). The Step-by-Step (original) approach had the highest sensitivity (97.7%). Lab-score had the highest AUC of 0.695 (95% CI 0.621-0.768), compared to PECARN rule at 0.625 (95% CI 0.556-0.694) and Step-by-Step (original) at 0.573 (95% CI 0.502-0.644). In predicting IBIs, PCT ≥1.7 had the highest sensitivity, specificity, PPV and NPV. The Step-by-Step (original and modified) approach had the highest sensitivity of 100%. Lab-score had the highest AUC of 0.854 (95% CI 0.731-0.977) compared to PECARN rule at 0.589 (95% CI 0.420-0.758) and Step-by-Step at 0.562 (95% CI 0.392-0.732). CRP strongly predicted SBIs, and PCT strongly predicted IBI. The Step-by-Step approach had the highest sensitivity and NPV, while Lab-score had the highest specificity and AUC in predicting SBIs and IBIs.

21 Emergency Department Observation of Children With Minor Blunt Head Trauma

The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules suggest a period of observation prior to decision-making regarding computed tomography (CT) in children with minor blunt head trauma (BHT) who are not immediately identified as high- or very low-risk of clinically important TBI (ciTBI). We sought to evaluate the role of observation in the management of children with minor BHT.

Predictability and stability testing to assess clinical decision instrument performance for children after blunt torso trauma.

The Pediatric Emergency Care Applied Research Network (PECARN) has developed a clinical-decision instrument (CDI) to identify children at very low risk of intra-abdominal injury. However, the CDI has not been externally validated. We sought to vet the PECARN CDI with the Predictability Computability Stability (PCS) data science framework, potentially increasing its chance of a successful external validation. We performed a secondary analysis of two prospectively collected datasets: PECARN (12,044 children from 20 emergency departments) and an independent external validation dataset from the Pediatric Surgical Research Collaborative (PedSRC; 2,188 children from 14 emergency departments). We used PCS to reanalyze the original PECARN CDI along with new interpretable PCS CDIs developed using the PECARN dataset. External validation was then measured on the PedSRC dataset. Three predictor variables (abdominal wall trauma, Glasgow Coma Scale Score <14, and abdominal tenderness) were found to be stable. A CDI using only these three variables would achieve lower sensitivity than the original PECARN CDI with seven variables on internal PECARN validation but achieve the same performance on external PedSRC validation (sensitivity 96.8% and specificity 44%). Using only these variables, we developed a PCS CDI which had a lower sensitivity than the original PECARN CDI on internal PECARN validation but performed the same on external PedSRC validation (sensitivity 96.8% and specificity 44%). The PCS data science framework vetted the PECARN CDI and its constituent predictor variables prior to external validation. We found that the 3 stable predictor variables represented all of the PECARN CDI's predictive performance on independent external validation. The PCS framework offers a less resource-intensive method than prospective validation to vet CDIs before external validation. We also found that the PECARN CDI will generalize well to new populations and should be prospectively externally validated. The PCS framework offers a potential strategy to increase the chance of a successful (costly) prospective validation.

A proposed algorithm for evaluation and management of pediatric hemophilia patients who present to the emergency department with head trauma.

Hemophilia is the deficiency of plasma clotting factor VIII (hemophilia A) or IX (hemophilia B) where management focuses on the prevention and treatment of acute bleeding symptoms and their sequelae. The most concerning risk is for life-threatening bleeding, including intracranial hemorrhage (ICH), which is caused by head trauma. Guidelines exist for the evaluation and management of pediatric head trauma, including the Pediatric Emergency Care Applied Research Network (PECARN) protocol, but limited evidence exists for when hemophilia patients present to the emergency department (ED), specifically with head trauma. Literature is limited regarding ICH and hemophilia, which further supports the culture of uncertainty among providers. The objective of this study is to conduct a retrospective chart review to determine the prevalence and clinical characteristics of ICH, and to describe computed tomography (CT) scan use in hemophilia patients who present to Phoenix Children's Hospital (PCH) ED with head trauma from January 1, 2007 to June 1, 2019. A total of 89 ED visits and 43 patients met inclusion criteria, and prevalence of ICH was determined to be 4% with the patients presenting with varied clinical characteristics and few commonalities. Using these data, we propose a new algorithm to aid clinicians in determining the need for CT scan in pediatric hemophilia patients who present to the ED with head trauma.

Deep Neural Networks Predict the Need for CT in Pediatric Mild Traumatic Brain Injury: A Corroboration of the PECARN Rule.

Only 10% of CT scans unveil positive findings in mild traumatic brain injury, raising concerns of its overuse in this population. A number of clinical rules have been developed to address this issue, but they still suffer limitations in their specificity. Machine learning models have been applied in limited studies to mimic clinical rules; however, further improvement in terms of balanced sensitivity and specificity is still needed. In this work, the authors applied a deep artificial neural networks (DANN) model and an instance hardness threshold algorithm to reproduce the Pediatric Emergency Care Applied Research Network (PECARN) clinical rule in a pediatric population collected as a part of the PECARN study between 2004 and2006. The DANN model was applied using 14,983 patients younger than 18 years with Glasgow Coma Scale scores ≥ 14 who had head CT reports. The clinical features of the PECARN rules, PECARN-A (group A, age < 2 years) and PECARN-B (group B, age ≤ 2 years), were used to directly evaluate the model. The average accuracy, sensitivity, precision, and specificity were calculated by comparing the model's prediction outcome to that reported by the PECARN investigators. The instance hardness threshold and DANN model were applied to predict the need for CT in pediatric patients using 5-fold cross-validation. In the first phase, the DANN model resulted in 98.6% sensitivity and 99.7% specificity for predicting the need for CT using the predictors of the two PECARN clinical rules combined to train the model. In the second phase, the DANN model was superior to both the PECARN-A and PECARN-B rules using the predictors for each age group separately to train the model. Compared with the clinical rule, for group A, the model achieved an average sensitivity (93.7% versus 100%) and specificity (97.5% versus 53.6%); for group B, the average sensitivity of the model was 99.2% versus 98.6%, and the specificity was 98.8% versus 58.2%. In this study, a DANN model achieved comparable sensitivity and outstanding specificity for replicating the PECARN clinical rule and predicting the need for CT in pediatric patients after mild traumatic brain injury compared with the original statistically derived clinical rule.

Updated Diagnosis Grouping System for Pediatric Emergency Department Visits.

This study aims to update the Diagnosis Grouping System (DGS) for International Classification of Disease, Tenth Revision ( ICD-10 ) codes for ongoing use. The DGS was developed in 2010 using ICD-9 codes with 21 major groups and 27 subgroups to facilitate research on pediatric patients presenting to emergency departments and required updated classification for more recent ICD codes. All emergency department discharges available in the Pediatric Emergency Care Applied Research Network (PECARN) database for 2016 were included to identify ICD-10 codes. These codes were then mapped onto the DGS codes originally derived from ICD-9 . We used ICD-10 codes from the PECARN database from 2017 to 2019 to confirm validity. The DGS was updated with ICD-10 codes based on 2016 PECARN data, and this updated DGS was successfully applied to 6,853,479 (97.3%) of all codes from 2017 to 2019. Using ICD-10 codes from the PECARN Registry, the DGS was updated to reflect ICD-10 codes to facilitate ongoing research.

Validity of Pediatric Emergency Care Applied Research Network (PECARN) in Pediatric Trauma Patients - A Cross Sectional Study from a Tertiary Care Hospital in Pakistan

Introduction: Head trauma in the pediatric age group is a common presentation in the Emergency Room (ER). The Pediatric Emergency Care Applied Research Network (PECARN) tool can help an ER clinician to identify pediatric head trauma patients at very low risk of clinically important traumatic brain injuries (ciTBIs) and avoid unnecessary CT scans. Objective: To determine the validity of PECARN rule as compared to the head CT (gold standard) in identifying low risk traumatic brain injury pediatric patients. Methods: A cross-sectional study was done at Aga Khan University Hospital (AKUH) Emergency Department ED. All pediatric head trauma patients were included in this study between 2017-2019. A total of 218 head trauma cases were reviewed which were evaluated for the PECARN criteria. Data were extracted on a prepared data collection form. Data were entered and analyzed using SPSS. Chi-square test was used. Results: Among the total 218, 190 cases (87%) had CT scans ordered. Out of these 190 patients 156 (82%) met PECARN criteria, while 34 (18%) were PECARN negative. The sensitivity and specificity of PECARN was calculated as 82% and 33% respectively, with a fair level of agreement with CT scan based on Kappa statistics. Conclusion: PECARN has a higher sensitivity but lower specificity in comparison to CT scan.

Validation of the Pediatric Sequential Organ Failure Assessment Score and Evaluation of Third International Consensus Definitions for Sepsis and Septic Shock Definitions in the Pediatric Emergency Department

Pediatric sepsis definitions have evolved, and some have proposed using the measure used in adults to quantify organ dysfunction, a Sequential Organ Failure Assessment (SOFA) score of 2 or more in the setting of suspected infection. A pediatric adaptation of SOFA (pSOFA) showed excellent discrimination for mortality in critically ill children but has not been evaluated in an emergency department (ED) population. To delineate test characteristics of the pSOFA score for predicting in-hospital mortality among (1) all patients and (2) patients with suspected infection treated in pediatric EDs. This retrospective cohort study took place from January 1, 2012, to January 31, 2020 in 9 US children's hospitals included in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. The data was analyzed from February 1, 2020, to April 18, 2022. All ED visits for patients younger than 18 years were included. ED pSOFA score was assigned by summing maximum pSOFA organ dysfunction components during ED stay (each 0-4 points). In the subset with suspected infection, visit meeting criteria for sepsis (suspected infection with a pSOFA score of 2 or more) and septic shock (suspected infection with vasoactive infusion and serum lactate level >18.0 mg/dL) were identified. Test characteristics of pSOFA scores of 2 or more during the ED stay for hospital mortality. A total of 3 999 528 (female, 47.3%) ED visits were included. pSOFA scores ranged from 0 to 16, with 126 250 visits (3.2%) having a pSOFA score of 2 or more. pSOFA scores of 2 or more had sensitivity of 0.65 (95% CI, 0.62-0.67) and specificity of 0.97 (95% CI, 0.97-0.97), with negative predictive value of 1.0 (95% CI, 1.00-1.00) in predicting hospital mortality. Of 642 868 patients with suspected infection (16.1%), 42 992 (6.7%) met criteria for sepsis, and 374 (0.1%) met criteria for septic shock. Hospital mortality rates for suspected infection (599 502), sepsis (42 992), and septic shock (374) were 0.0%, 0.9%, and 8.0%, respectively. The pSOFA score had similar discrimination for hospital mortality in all ED visits (area under receiver operating characteristic curve, 0.81; 95% CI, 0.79-0.82) and the subset with suspected infection (area under receiver operating characteristic curve, 0.82; 95% CI, 0.80-0.84). In a large, multicenter study of pediatric ED visits, a pSOFA score of 2 or more was uncommon and associated with increased hospital mortality yet had poor sensitivity as a screening tool for hospital mortality. Conversely, children with a pSOFA score of 2 or less were at very low risk of death, with high specificity and negative predictive value. Among patients with suspected infection, patients with pSOFA-defined septic shock demonstrated the highest mortality.

Non-ionizing Imaging for the Emergency Department Assessment of Pediatric Minor Head Trauma.

Minor blunt head trauma (MHT) represents a common reason for presentation to the pediatric emergency department (ED). Despite the low incidence of clinically important traumatic brain injuries (ciTBIs) following MHT, many children undergo computed tomography (CT), exposing them to the risk associated with ionizing radiation. The clinical predictions rules developed by the Pediatric Emergency Care Applied Research Network (PECARN) for MHT are validated accurate tools to support decision-making about neuroimaging for these children to safely reduce CT scans. However, a few non-ionizing imaging modalities have the potential to contribute to further decrease CT use. This narrative review provides an overview of the evidence on the available non-ionizing imaging modalities that could be used in the management of children with MHT, including point of care ultrasound (POCUS) of the skull, near-infrared spectroscopy (NIRS) technology and rapid magnetic resonance imaging (MRI). Skull ultrasound has proven an accurate bedside tool to identify the presence and characteristics of skull fractures. Portable handheld NIRS devices seem to be accurate screening tools to identify intracranial hematomas also in pediatric MHT, in selected scenarios. Both imaging modalities may have a role as adjuncts to the PECARN rule to help refine clinicians’ decision making for children at high or intermediate PECARN risk of ciTBI. Lastly, rapid MRI is emerging as a feasible and accurate alternative to CT scan both in the ED setting and when repeat imaging is needed. Advantages and downsides of each modality are discussed in detail in the review.

Injury Characteristics Among Pediatric Athletes Who did and did not Undergo a CT Scan Following Concussion

Background:CDC and AAP guidelines discourage routine neuroimaging following concussion, as CT scans are only indicated if severe intracranial injury is suspected. Validated prediction rules such as Pediatric Emergency Care Applied Research Network (PECARN) criteria have decreased the number of unnecessary pediatric head CTs; however, are still commonly performed following pediatric sport-related concussion (SRC).Hypothesis/Purpose:To determine differences in injury characteristics and outcomes in athletes who did and did not undergo head CT following SRC.Methods:Data were prospectively collected from participants enrolled in the North Texas Concussion Network Registry (ConTex) between August 2015-May 2021. Participants aged 5-18 diagnosed with SRC and presenting within 30 days were included. Participants were separated into 2 groups based on whether they had a CT scan following SRC: CT (negative scan) and no CT. Positive CTs were excluded. Groups were matched in age and time to presentation (≤14, >14-30 days). Demographics, concussion-related details, and 3-month outcome variables were analyzed including days to symptom resolution (≤30 vs >30 days) and return-to-play (RTP).Results:324 participants were included: 162 in each group. There were no significant differences between the groups in sex, race, ethnicity, or previous concussion history. Differences in injury-related characteristics are reported in Table 1. Participants in the CT group were more likely to be participating in unorganized events (p=0.05), and less likely to continue playing following SRC (p=0.003) than the no CT group. The CT group more frequently reported head to surface mechanism of injury than the no CT group. Significantly higher rates of loss of consciousness (LOC), amnesia, and vomiting following SRC were reported in the CT group. At 3-months post-SRC, the no CT group reported RTP a week sooner than the CT group (28.8±22.3 vs 35.7±27.3 days, p=0.019). However, there was no difference in prolonged recovery (>30 days: 29.6 vs 40.5%, p=0.07) or overall RTP rates (91.9 vs 85.8%, p=0.09) between the no CT and CT groups.Conclusion:Pediatric athletes who underwent CT following SRC exhibited significantly different injury-related characteristics compared to those who did not, but the differences observed did not impact symptom resolution or return-to-play. While LOC and vomiting differences align with the PECARN prediction rules and likely contribute to decision to perform CT, the additional differences of participating in an unorganized event, head-to-surface impact, and amnesia are not part of PECARN criteria. Further research is needed to discover which variables may contribute to unnecessary head CTs following SRC.Table 1.Injury related characteristics between the CT and no CT scan groups

199 Diversity Among Research Coordinators in a Pediatric Emergency Medicine Collaborative Research Network

OBJECTIVES/GOALS: Our primary objective was to determine the demographic and linguistic characteristics of research coordinators (RCs) in a large pediatric emergency medicine research collaborative network. Our secondary objective was to determine if the RCs perceived any impact of those characteristics on their duties. METHODS/STUDY POPULATION: We conducted a 15-question electronic survey of RCs at the member institutions of the Pediatric Emergency Care Applied Research Network (PECARN). A total of 74 potential respondents were identified and received the survey. RESULTS/ANTICIPATED RESULTS: Fifty-three surveys (71.6%) were completed. Most respondents identified as female; white; and not Hispanic or Latino. Fourteen respondents (26.4%) identified as underrepresented minorities in medicine (UIM), which is similar to the percentage of UIM among the general population (30%). Twenty-eight respondents (52%) felt that their race/ethnicity positively impacted recruitment efforts. Twenty-three respondents (43%) felt that their ability to speak a language other than English positively impacted recruitment efforts. Four female respondents felt that their gender hindered their recruitment activities and impacted their sense of belonging within the research team. DISCUSSION/SIGNIFICANCE: RCs felt that their backgrounds and attributes positively impacted subject recruitment. However, some female coordinators felt negatively impacted by their gender. Increasing diversity amongst clinical research professionals and incorporating team cultural humility practices, may help increase diversity among clinical research subjects.

Cost-effectiveness of patient observation on cranial CT use with minor head trauma

ObjectiveTo evaluate the cost-effectiveness of planned observation on cranial CT use in children with minor head trauma.DesignPlanned secondary analysis of a multicentre prospective observation study.SettingAustralia and New Zealand.PatientsAn analytic cohort...

Risk-stratification in febrile infants 29 to 60\u2009days old: a cost-effectiveness analysis

BackgroundMultiple clinical prediction rules have been published to risk-stratify febrile infants ≤60 days of age for serious bacterial infections (SBI), which is present in 8-13% of infants. We evaluate the cost-effectiveness of strategies to identify infants with SBI in the emergency department.MethodsWe developed a Markov decision model to estimate outcomes in well-appearing, febrile term infants, using the following strategies: Boston, Rochester, Philadelphia, Modified Philadelphia, Pediatric Emergency Care Applied Research Network (PECARN), Step-by-Step, Aronson, and clinical suspicion. Infants were categorized as low risk or not low risk using each strategy. Simulated cohorts were followed for 1 year from a healthcare perspective. Our primary model focused on bacteremia, with secondary models for urinary tract infection and bacterial meningitis. One-way, structural, and probabilistic sensitivity analyses were performed. The main outcomes were SBI correctly diagnosed and incremental cost per quality-adjusted life-year (QALY) gained.ResultsIn the bacteremia model, the PECARN strategy was the least expensive strategy ($3671, 0.779 QALYs). The Boston strategy was the most cost-effective strategy and cost $9799/QALY gained. All other strategies were less effective and more costly. Despite low initial costs, clinical suspicion was among the most expensive and least effective strategies. Results were sensitive to the specificity of selected strategies. In probabilistic sensitivity analyses, the Boston strategy was most likely to be favored at a willingness-to-pay threshold of $100,000/QALY. In the urinary tract infection model, PECARN was preferred compared to other strategies and the Boston strategy was preferred in the bacterial meningitis model.ConclusionsThe Boston clinical prediction rule offers an economically reasonable strategy compared to alternatives for identification of SBI.

Validation of Pediatric Emergency Care Applied Research Network (PECARN) rule in children with minor head trauma.

The Pediatric Emergency Care Applied Research Network (PECARN) rule is commonly used for predicting the need for computed tomography (CT) scans in children with mild head trauma. The objective of this study was to validate the PECARN rule in Korean children presenting to the pediatric emergency department (PED) with head trauma. This study was a multicenter, retrospective, observational cohort study in two teaching PEDs in Korea between August 2015 and August 2016. In this observational study, 448 patients who visited PEDs were included in the final analysis. Risk stratification was performed with clinical decision support software based on the PECARN rule, and decisions to perform CT scans were subsequently made. Patients were followed-up by phone call between 7 days and 90 days after discharge from the PED. The sensitivity and specificity were analyzed. The sensitivity was 100% for all age groups, and no cases of clinically important traumatic brain injury (ciTBI) were identified in the very-low-risk group. CT scans were performed for 14.7% of patients in this study and for 33.8% in the original PECARN study. The PECARN rule successfully identified low-risk patients, and no cases of ciTBI were missed despite the reduced proportion of patients undergoing CT scans.

External validation of a pediatric decision rule for blunt abdominal trauma.

IntroductionBlunt traumatic injuries are a leading cause of morbidity and mortality in the pediatric population. Contrast‐enhanced multidetector computed tomography is the best imaging tool for screening patients at risk of blunt abdominal injury. The Pediatric Emergency Care Applied Research Network (PECARN) abdominal rule was derived to identify patients at low risk for significant abdominal injury who do not require imaging.MethodsWe conducted a retrospective review of pediatric patients with blunt trauma to validate the PECARN rule in a non‐pediatric specialized hospital from February 3, 2013, through December 31, 2019. We excluded those with penetrating or mild isolated head injury. The PECARN decision rule was retrospectively applied for the presence of a therapeutic intervention, defined as a laparotomy, angiographic embolization, blood transfusion, or administration of intravenous fluids for pancreatic or gastrointestinal injury. Sensitivity and specificity analysis were conducted along with the negative and positive predictive values.ResultsA total of 794 patients were included in the final analysis; 23 patients met the primary outcome for an acute intervention. The PECARN clinical decision rule (CDR) had a sensitivity of 91.3%, a negative predictive value of 99.5, and a negative likelihood ration of 0.16.ConclusionIn a non‐pediatric specialty hospital, the PECARN blunt abdominal CDR performed with comparable sensitivity and negative predictive value to the derivation and external validation study performed at specialized children's hospitals.

Comparison of PECARN clinical decision rule and clinician suspicion in predicting intra-abdominal injury in children with blunt torso trauma in the emergency department.

The Pediatric Emergency Care Applied Research Network (PECARN) developed a clinical decision rule to identify children at low risk for intra-abdominal injury requiring acute intervention (IAI-I) for reducing unnecessary radiation exposure of ab-dominal computed tomography (CT) after blunt torso trauma. This study aimed to compare the PECARN decision rule with clinician suspicion in identifying children at low risk of intra-abdominal injuries that an abdominal CT scan can be safely avoided. This study is a retrospective review of children with blunt torso trauma in an academic emergency department (ED) between 2011 and 2019. Patients were considered positive for the PECARN rule if they exhibited any of the variables. Clinician suspi-cion was defined as actual CT ordering of the treating physician. The primary outcome was IAI-I detected by imaging or surgery within 1 month after the trauma, and the secondary outcome was any intra-abdominal injury (IAI) presence. Among the 768 children included, 48 (6.25%) had intra-abdominal injuries and 21 (2.73%) of whom underwent acute in-tervention. Four hundred and fifty-three (59%) children underwent abdominal CT scanning. If the PECARN rule had been applied, 232 patients would have undergone abdominal CT. The rule revealed 90.48% (95% CI=68.17-98.33%) sensitivity for IAI-I and 81.25% (95% CI=66.9-90.56%) for IAI. Clinician suspicion revealed sensitivities of 100% (95% CI=80.76-00%) and 93.75% (95% CI=81.79-98.37%) for IAI-I and IAI, respectively. Sensitivities of the rule and clinician suspicion were statistically similar for both IAI-I (p=0.5) and IAI (p=0.146). In this study, the PECARN abdominal rule and clinician suspicion performed similarly in identifying intra-abdominal injuries in children with blunt torso trauma. However, our study supports the use of PECARN abdominal rule in addition to clinical judgment to limit unnecessary abdominal CT use in pediatric patients with blunt torso trauma in the ED.

Accuracy of Pediatric Emergency Care Applied Research Network Rules in Predicting Brain Injuries

Background and Objectives: Head trauma is one of the most important causes of emergency department (ED) visits and the leading cause of disability and mortality in children. The aim of this study was to evaluate the Pediatric Emergency Care Applied Research Network (PECARN) rules to predict brain injuries in pediatrics with head trauma. Materials and Methods: This descriptive–analytic study was performed on 250 pediatric patients with head trauma referred to Imam Reza Hospital in Tabriz City from August to September 2020. All patients were evaluated in the ED for the existing of any rules of the PECARN, then the results of the PECARN rules and brain computed tomography (CT) scan findings were compared in these patients. According to the PECARN rules, patients were classified into three categories, namely low, moderate, and high risk. For all three groups, if there is an indication of brain CT scan, it was performed and reported by an emergency medicine specialist. Results: The mean age of the patients was 88 months. In this study, 162 (64.8%), 42 (16.8%), and 46 (18.4%) patients were in the low-risk, moderate-risk, and high-risk groups, respectively. Death was occurred in 18 (12.8%) patients. Results showed a statistically significant association between positive CT findings and some variables, such as behavioral change, vomiting, severe headache, LOC over 5 s, confusion, palpable skull fracture, skull base fracture, and the severe mechanism of injury (P < 0.05). Furthermore, a statistically significant association was found between PECARN rules and CT findings (P < 0.001). Conclusions: According to the results of the present study, PECARN rules have a significant association with brain CT scan findings. Therefore, using these rules is recommended to reduce the number of brain CT scan requests for pediatric patients.

Evaluation of feedback modalities and preferences regarding feedback on decision-making in a pediatric emergency department.

To compare pediatric emergency clinicians' attitudes toward three feedback modalities and assess clinicians' case-based feedback preferences. Electronic survey sent to pediatric emergency medicine (PEM) physicians and fellows; general pediatricians; and advanced practice providers (APPs) with nine questions exploring effectiveness and emotional impact of three feedback modalities: case-based feedback, bounce-back notifications, and biannual performance reports. Additional questions used a four-point ordinal agreement response scale and assessed clinicians' attitudes toward case review notification, case-based feedback preferences, and emotional support. Survey responses were compared by feedback modality using Pearson's chi-squared. Of 165 eligible providers, 93 (56%) responded. Respondents agreed that case-based feedback was timely (81%), actionable (75%), prompted reflection on decision-making (92%), prompted research on current clinical practice (53%), and encouraged practice change (58%). Pediatric Emergency Care Applied Research Network (PECARN) performance reports scored the lowest on all metrics except positive feedback. No more than 40% of providers indicated that any feedback modality provided emotional support. Regarding case-based feedback, 88% of respondents desired email notification before case review and 88% desired feedback after case review. Clinicians prefer receiving feedback from someone with similar or more experience/training. Clinicians receiving feedback desire succinctness, supporting evidence, consistency, and sensitive delivery. Case-based feedback scored highest of the three modalities and is perceived to be the most likely to improve decision-making and promote practice change. Most providers did not perceive emotional support from any feedback modality. Emotional safety warrants purposeful attention in feedback delivery. Critical components of case-based feedback include succinctness, supporting evidence, consistency, and sensitive delivery.

CT Trends After Minor Head Injury Guideline Implementation

Source: Corwin DJ, Durbin DR, Hayes KL, et al. Trends in emergent head computed tomography utilization for minor head trauma after implementation of a clinical pathway. Pediatr Emerg Care. 2021;37(9);437-441; doi:10.1097/PEC.0000000000001728Investigators from the Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA, conducted a retrospective study to assess changes in neuroimaging among children seen in the ED for mild traumatic brain injury (TBI) following implementation of guidelines designed to reduce unnecessary CT scans. The guidelines, implemented in 2011, were adapted from guidelines published by the Pediatric Emergency Care Applied Research Network (PECARN) that included specific clinical criteria for identifying children at low risk.1 Study participants were patients ≤21 years old seen in the ED at CHOP between 2012 and 2016 with TBI (identified using ICD-9 and ICD-10 codes) with a Glasgow Coma Scale score of 13–15 who were discharged home following evaluation. Data abstracted on these children included demographics, time of day, provider type (general pediatrician, pediatrician emergency physician, or nurse practitioner), whether a CT was obtained, and Emergency Severity Index (ESI) score. ESI scores range from 1–5, with 1 being the most acute. The medical records of a random sample of 10% of patients on whom a CT was obtained were reviewed to assess the reason for obtaining the scan and to classify the child’s risk for intracranial injury based on PECARN criteria. The primary outcome was change in rate of CT utilization during the study period, assessed using Wilcoxon rank sum test for trend. Secondary outcomes included rate of ordering CT scans by provider type, using logistic regression and adjusting for ESI scores.Data were analyzed on 21,129 patients with a mean age of 6.6 years; 62% were male. Overall, CT scans were obtained on 6.3% (95% CI, 5.9%, 6.6%) of these patients. During the study period the rate of CT scan utilization fell from 8.3% in 2012 to 4.9% in 2016 (average decrease 0.9% per year; P <0.001 for trend). After adjusting for ESI score, general pediatricians were more likely to obtain a CT scan than pediatric emergency physicians (OR, 1.37; 95% CI, 1.02, 1.83); there was no difference in likelihood of ordering a CT between nurse practitioners and pediatric emergency physicians (OR, 0.63; 95% CI, 0.33, 1.17). In the 10% random sample of patients on whom CT scans were obtained, 30% met PECARN criteria for being low risk. The most common indications for ordering a CT in children <2 years old were concern for non-accidental trauma and vomiting, while for older patients the most common reasons were parental preference and presence of a scalp hematoma.The authors conclude the rate of CT scan ordering in children with mild TBI decreased after implementation of guidelines designed to reduce unnecessary neuroimaging.Dr Bechtel has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Clinical pathways (CPWs) are tools to promote evidence-based healthcare delivery and strive to standardize care for a specific clinical problem in a specific population.2 Thus, compliance with a CPW by a diverse swath of healthcare providers is ultimately the best indicator of its relevance and utility. The primary objective of the current well-done study was to assess the pattern of change in CT utilization in discharged children with mild TBI following the implementation of a CPW in a children’s ED.The authors found that for 5 years, the rate of obtaining CT in children discharged with minor TBI declined by 0.9% per year, a statistically significant decrease, without an accompanying increase of LOS in the ED. However, despite these guidelines, 30% of surveyed Electronic Health Records (EHRs) of discharged children were characterized as low risk by the guidelines and still had a CT obtained. When documented in the EHR, the most common indications for obtaining a CT in this population were age specific. For example, in children younger than 2 years, providers were more concerned about the presence of abusive trauma and vomiting, whereas, in children older than 2 years, parental preference and scalp hematomas drove CT utilization. It may be noted that updated PECARN guidelines do not use vomiting as a risk factor, while parental preference is still a consideration in choosing CT over observation.3 The other interesting finding was that general pediatricians were more likely to order a CT compared with emergency medicine providers. Thus, the dissemination of this CPW to general pediatricians would be helpful to reduce CT use further. (See AAP Grand Rounds. 2017;37[6]:68.)4A CPW for the management of minor closed head trauma in children can lead to the reduction in the utilization of head CTs in childrenAbove and beyond decreasing unnecessary use of expensive resources and decreasing length of ED stay, decreased cranial CT frequency in children with minor TBI reduces exposure to potentially harmful ionizing radiation.4